Wednesday, 23 October 2013

The percentage of live spermatozoa is
assessed by identifying those with an intact cell membrane, by dye exclusion test or
by hypo-osmotic swelling test.

The lower reference limit for vitality (membrane-intact spermatozoa) is 58%.

When?

When the percentage of sperm motility is low or absent,
vitality tests are used in order to determine whether spermatozoa have lost
their flagellation because of metabolic dysfunction and/or axonemal defects, or
are simply dead (necrozoospermia). When ART is considered, viable sperms are picked out for use. Vitality results should be assessed in
conjunction with motility results from the same semen sample. Necrozoospermia
may indicate epididymal pathology. Vitality tests are routinely performed on
all samples by some. They also provide a check on the motility evaluation, since the
percentage of dead cells should not exceed the percentage of immotile
spermatozoa. Vitality should be assessed as soon as possible after liquefaction
of the semen sample, preferably at 30 minutes, but in any case within 1 hour of
ejaculation, to prevent observation of deleterious effects of dehydration or of
changes in temperature on vitality.

Nigrosin is used to increase the contrast
between the background and the sperm heads, which makes them easier to
discern. It also permits slides to be stored for re-evaluation and
quality-control purposes. Spermatozoa with red /dark pink heads are considered dead, whereasspermatozoa with white/light pink
heads are consideredalive. If the stain is limited to only a
part of the neck region, and the rest of the head area is unstained, this is
considered a“leaky neck membrane”, not a sign of cell
deathand the sperm is considered alive. If eosin is used alone, it might be
difficult to discern the pale pink stained heads, in such circumstances
nigrosin is used to increase the contrast of the background.

Sperms are killed in the vital staining process andcannotbe used subsequently for ART.

Hypo-osmotic swelling (HOS) test

It is test of the integrity of the
semi-permeable plasma membrane of the viable sperm tail. If live sperms are
placed in hypotonic solution, water will enter the cell and cause the cell to
increase in volume; this becomes evident inthe tail region where swelling
of the sperm tail can be easily seen.

Sperms are not killed during the test and the test can be
used in a therapeutic manner for ART including testicular sperm extraction
(when only non-motile sperms are present, the test allows the technician to
pick out viable non-motile sperm).It should be noted that the time and preparing the
reagents differ between diagnostic use and therapeutic use.

*Eosin (Greek, Eos goddess of dawn) isared dye resulting
from the action of bromine on fluorescein. Structures that stain
readily with eosin are termed eosinophilic. There are closely related
interchangeable compounds commonly referred to as eosin. These are the one
usually used eosin Y (with very faint yellowish cast), and eosin B (with very
faint bluish cast).

What else to be considered?

1 1) The possibility of
the semen specimen being exposed to contaminants within the container or to
extremes of temperature, or prolonged abstinence periods. Also,
consider the possibilities of genital tract infections and varicocele. 2) Defective transport through the genital system. 3) Antisperm antibody assay. It
is preferable to use direct assays since these determine the presence of
sperm-bound antisperm antibodies, as compared with indirect assays that
determine the presence of antisperm antibodies in serum. 4) Electron microscopy studies
for ultra-structural defects (commonest is immotile cilia syndrome).

Tuesday, 17 September 2013

Eruptive vellus hair cysts (occlusion and cystic
dilatation of vellus hair follicles) commonly
present as asymptomatic small red, yellow, bluish-grey or brown, papules (occasionally
scaly) on the chest, abdomen (A), and axillae (B) in the second decade of life. They were first reported in 1977. The diagnosis is often made clinically,
because of typical age of onset (before puberty), the site of the lesions, and their appearance.Histopathologic examination reveals a cystic
structure located in the middle or upper dermis. It is lined by a stratified
squamous epithelium with focal features of outer root sheath differentiation at
the level of the follicular isthmus and trichilemmal cornification. The lumen
contains keratin and numerous transversely and obliquely sectioned vellus hair
shafts. Some cysts may show a connecting
pore at the skin surface, the likely mechanism of the spontaneous regression.Also, incision or
puncture of the cyst and examination of the contents in potassium
hydroxide, under a microscope will reveal the vellus
hairs. Eruptive vellus hair cysts can
overlap clinically and pathologically with steatocystoma multiplex (hybrid cysts). The so-called steatocystoma multiplex suppurativamimics acne conglobata. Twenty-five percent of eruptive vellus
hair cysts cases spontaneously regress through transepidermal elimination. Various methods have been used to treat the lesions but
beware of scarring. The lesions may clear after application of topical
retinoids. Erbium: YAG laser has been successful in treating the lesions*.

Friday, 13 September 2013

Sexual contact is the most common route of HIV
transmission*whose rate of infection after a sexual contact
varies according to the nature of the contact and whether it is protected or
not and the HIV subtype. The search for potential vaccines has yielded little
result. Oral antiretrovirals, life saving drugs for HIV-infected
patients, have a role to play among other means in the prevention of sexually
transmitted HIV infection in at-risk HIV negative populations. In this
context, they are used for pre-sexual exposure prophylaxis (PrSEP), post-sexual
exposure prophylaxis and early treatment of the HIV-infected partners. Other means
include topical antiretrovirals, male circumcision and male/female condoms. Certainly abstinence is the
definitive way for prevention of any sexually transmitted infection.
Pre-exposure prophylaxis that is shown to be effective in reducing HIV
transmission in one population may not necessarily work in other at-risk
populations, hence the conduction of trials in different population groups
representing different routes of HIV transmission, including heterosexuals,
MSM, and injecting drug abusers.The concept of providing pre-exposure prophylaxis
is not new. Apart from vaccines, a famous example is the
pre-exposure prophylaxis against malaria for travellers to endemic areas. Theoretically, if
HIV replication is inhibited from the moment the virus enters the body, it may
not be able to establish a permanent infection. PrSEP has
been shown to reduce the risk of HIV infection among adult men and women at
high risk for HIV infection through sex. The FDA has
approved the combination medication tenofovir disoproxil fumarate plus
emtricitabine for use as PrSEP among sexually active adults at risk
for HIV infection.At-risk populations such as MSM are
not necessarily aware of the presence of PrSEP. However, knowledge about
this role of oral antiretrovirals may have effect on willingness to accept it. Serodiscordant
couples have been advised of early treatment for the infected partner, PrSEP
for the uninfected partner, or a combination of the two. PrSEP might be an
effective prevention method for women who are unable, for
whatever reason, to negotiate condom use. PrSEP might also be used as a risk reduction strategy for HIV negative women who request to conceive naturally from HIV positive men via timed unprotected sex, PrSEP for conception (PrSEP-C).

It should be noted however that PrSEP can give a false sense of security that might
lead to easier transmission of other sexually transmitted infections. Moreover, continued use of a PrSEP regimen in the
presence of undiagnosed HIV infection is analogous to the HIV monotherapy or
dual therapy strategies used in the early stages of the HIV epidemic. Such regimens are known to carry an
unacceptably high risk of HIV drug resistance, with important clinical implications for the
patient and public health implications for the sexual partners. Extensive studies are needed to address thesafety concernsassociated
with use of daily oral PrSEP in HIV negative people, whether in long or
short term courses, and to address cost concerns of PrSEP and feasibility to deliver it.

*National statistics show injection drug use is the principal mode of HIV transmission in Iran.

Monday, 9 September 2013

Papillon-Léfèvre syndrome is a very rare syndrome of autosomal recessive inheritance (the prevalence has been estimated as 1–4 in 1 million) characterised by palmoplantar keratoderma (A), and periodontitis (C). The lesions may extend to the dorsal hands and feet and may also be present on the elbows, knees (B), and Achilles tendon areas. The condition usually has an early age of onset. The severity of the periodontal disease doesnot correlate with the severity of the skin lesions. Periodontitis leads to the loss of deciduous teeth by the age of 5 years unless treated; permanent teeth may be lost in the same way. Associated hyperhidrosis causes an unpleasant odour. The hair is usually normal. Other associated features have been reported such as pyogenic infections of the skin and internal organs and pseudoainhum of the thumb.

This condition is caused by a mutation in the lysosomal protease cathepsin C gene located at chromosome 11q14.1–q14.3. This explains the predisposition to pyogenic infection, but the mechanism of keratoderma is not established.The phenotypically related Haim–Munk syndrome (it combines the features of Papillon–Léfèvre syndrome with onychogryphosis, arachnodactyly and acro-osteolysis) is an allelic mutation. Theremay be mild phenotypic expression of the disease with late onset and mild skin or periodontal disease.In some late-onset patients, no mutationsin the cathepsin C gene were found, suggesting the possibility ofanother genetic cause.Periodontitis is also present in the ‘HOPP’ syndrome (hypotrichosis, acro-osteolysis, palmoplantar keratoderma, and periodontitis) but there is no mutation in the cathepsin C gene.

Histopathological changes are non-specific. Treatment with oral acitretin has been effective in controlling the disease.

A

B

C

This child has presented with hyperkeratosis of the palms and soles that has first developed during the first few months of life. The
lesions spread on the elbows and knees over the following
years. On examination, loss of dentition has also been noted. It has started since the eruption of deciduous
teeth. A diagnosis of Papillon-Léfèvre syndrome was made. Treatment
with acitretin has been discussed with the mother and it was decided to
postpone it in view of the possible side-effect of premature epiphyseal closure. The patient is
currently being treated with topical preparations for symptomatic relief.

Friday, 26 April 2013

Melanonychia is a brown to black colour of the nail. It is due to the presence of melanin
in the nail plate. It is caused by activation or benign/malignant proliferation
of nail matrix melanocytes.

When the pigmentation involves the whole nail
it is called total melanonychia. When it is banded it is either transverse or
longitudinal. Longitudinal melanonychia is the commonest form. The commonest
cause of longitudinal melanonychia in adults is racial variation (see photo), trauma has been implicated in their development. The
commonest cause in children is benign melanocytic
hyperplasia.

Longitudinal melanonychia of a single nail deserves biopsy
in adultsas a high degree of suspicion is required if subungual melanoma
is not to be missed. In children it is usually benign
in nature and can be followed.

Thursday, 14 March 2013

Pimecrolimus inhibits
the release of both preformed and de novo synthesized mediators from activated
mast cells and inhibits accumulation of mast cells by inducing apoptosis.Thus pimecrolimus and tacrolimus
are now considered as a potential therapeutic approach for mast cell-associated
diseases such as mastocytosis.

This child skin showed multiple, generalized tan to brown macules/papules with classic features. Pigmentation and all evidence of the disease commonly disappear within a few years, generally before puberty. The eruption, however, may uncommonly persist into adult life. Although systemic involvement is possible, malignant systemic disease is extremely rare.

Such lesions are often confused with insect bites at
first, but they persist and gradually increase in number for several months or
years.Many children and
adults have few, if any, symptoms. Childhood urticaria
pigmentosa usually develops in the first year of life. Adult urticaria pigmentosa usually
develops between 20 and 40 years. The lesions appear anywhere on the body but
classically sparing the central face, scalp, palms and soles. Stroking a
lesion with the blunt end
of a pen induces a weal of the entire lesion that is usually confined to the
stroked site (Darier's sign). The weal may take up to 10 minutes to appear. Stroking may also produce wealing in clinically unaffected skin.Darier’s sign is more pronounced in children due to a
higherdensity of mast cells and the rubbed area may even blister. This test is highly characteristic and is
usually seen as reliable as a biopsy for establishing the diagnosis. Having said so, Darier’s
sign is not always demonstrable and is not 100% specific for mastocytosis, since
it has also been described rarely in juvenile xanthogranuloma and acute
lymphoblastic leukaemia of neonates. Interestingly, juvenile xanthogranuloma has
been reported in association with urticaria pigmentosa*.

A skin biopsy is desirable to confirm a clinical diagnosis in many patients, although observation alone is appropriate in very young children. A full blood count should be performed at presentation and at yearly intervals when systemic disease is suspected. Other investigations should be guided by the clinical presentation. Juvenile xanthogranuloma is generally a self-healing tumourand lesions generally resolve in 1–5 years. Having said so, disseminated neonatal juvenile xanthogranuloma may be more aggressive and fatalities in this group have been reported. The major difficulty in clinical diagnosis of juvenile xanthogranuloma is with the nodular forms of Langerhans’ cell histiocytosis. Histopathology and immunocytochemistry will easily differentiate the two disorders. Some believe that benign cephalic histiocytosis represents a clinical variant of juvenile xanthogranuloma but the clinical features of the disease are distinct enough to maintain a separate nomenclature.﻿

Friday, 1 February 2013

Friday 15/2/13 1:30 pm Cairo Time Google Plus HangoutTopics:1-Clear cell acanthoma of Degos2-Acanthosis nigricans (obesity related) 3-Chlamydial urethritis4-Ross’s syndrome5-Snippets6-MCQsFree talks via Google Hangout on Fridays have been arranged. These Friday Meetings have been audiovisual online meetings where we have typed, talked and screen shared. TheHandouts, when available, can be emailed on request unless they become out-of-date.Similarly, Thursday Meetings have been developed to discuss Rook's Textbook of Dermatology on Google Hangout.

Thursday, 24 January 2013

Friday 25/1/13 1:30 pm Cairo Time Google Plus HangoutTopics:1-Secondary hyperkeratosis of the nipple and/or areola2-Hypopigmented parapsoriasis3-Update on ART4-Cases5-Snippets6-MCQsFree talks via Google Hangout on Fridays have been arranged. These Friday Meetings have been audiovisual online meetings where we have typed, talked and screen shared. TheHandouts, when available, can be emailed on request unless they become out-of-date.Similarly, Thursday Meetings have been developed to discuss Rook's Textbook of Dermatology on Google Hangout.

Friday, 11 January 2013

Annual ESDV Conference 2013Marriott Hotel, Zamalek, Cairo, EgyptUpdate on Antiretroviral Therapy (ART) for Treatment-Naive HIV-1 Adult PatientsThursday 17/1 at 10:50 amAbstract: There is no cure for HIV infection but treatment is aimed at reducing the plasma viral load as much as possible and for as long as possible. The most recent British HIV Association (BHIVA) treatment guidelines published in 2012 will be discussed in relation to treatment-naive adult patients. How to get ART in Egypt will be discussed too.Google Event Page

My About.Me

The Royal College of Physicians and Surgeons of Glasgow (RCPSG) Coat of Arms Symbolism

The RCPSG (a charity) was established by Royal Charter from King James VI of Scotland (James I of England) in 1599.

*The first and fourth quarters of the shield contain the lancet that represents the surgeons, and poppy that represents the laudanum used by the physicians and the snake-entwined staff that represents Aesculapius, Greek god of medicine.

*The second quarter of the shield contains the Royal Arms of Scotland (the lion of Scotland) and reflects the gift of the original charter from King James VI of Scotland (James I of England).

*The third quarter has the familiar arms of the City of Glasgow, reflecting the College's origins in Glasgow and the West of Scotland. There are the tree that never grew, the bird that never flew, the bell that never rang and the fish that never swam.

*The supporters are Hygeia (goddess of health) on the right, and on the left, Minerva (goddess of art and science).

*The crest is an antique lamp on an open book, which symbolises the light of learning dispelling the darkness of ignorance.

*The coat of arms has two mottoes. Above is "Conjurat Amice", translated as "We live together in amity". This reflects the unique nature of the RCPSG in encompassing physicians and surgeons, whereas those of Edinburgh and London are separate. The motto below the shield reads "Non vivere sed valere vita". It is an epigram of the Roman poet Martial and can be translated into English as "Not simply to live but to enjoy life".

Current Forms of Assessing Trainees (Dermatology, Venereology and Surgical Andrology)

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I cannot be held responsible for any consequences arising from the use of information contained in this publication.It is the ultimate responsibility of the medical practitioner to determine the best treatment for each patient.